DP13-1305 Domain 3
Resource Guide

Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation's signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform. AF4Q asks the people who get care, give care and pay for care to work together toward common, fundamental objectives to lead to better care. The 16 geographically, demographically, and economically diverse communities participating in AF4Q together cover 12.5 percent of the U.S. population.

Funder: Robert Wood Johnson Foundation

Reach: The 16 locations across the United States also referred to as alliances include Cleveland Ohio, Detroit Michigan, Greater Boston Massachusetts, Humboldt County California, Kansas City Missouri, Maine, Memphis Tennessee, Minnesota, New Mexico, Oregon, South Central Pennsylvania, Washington, West Michigan, Western New York, and Wisconsin.

Do they report NQF 18, NQF 59 or other CVH diabetes data? In some cases yes, however the various alliances have different goals and aims so data reporting does vary. You should check with the RWJF AF4Q website for specific details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures.

Cincinnati Aligning Forces for Quality (AF4Q), led by the Health Collaborative, is putting data to work to improve diabetes care among its patients. Starting in 2009, the Health Collaborative brought a group of physicians together to discuss what public reporting measures would be considered valuable to improving patient care. With the prevalence of diabetes in the Cincinnati area higher than the national average, the group chose to focus on those outcomes first. Physicians were provided with a "daily dashboard" of data. Dr. Michael Trombley, family physician at Mercy Health, said, "With real-time data we've been able to track if the changes we've made have been effective in improving patient care." In 2011 physicians were given five additional measures on their patients (the D5): blood pressure, cholesterol, blood sugar levels, tobacco use, and aspirin use. With the available data, the group of Cincinnati physicians has been successful in improving quality indicators of their patients by 27 percent.

For More Information Visit: Forces 4 Quality

Beacon is a federally funded grant program which provides communities with funding to build and strengthen their health information technology (health IT) infrastructure and exchange capabilities. The communities are demonstrating how hospitals, clinicians, and patients are meaningful users of health IT, and together the community achieves measurable improvements in health care quality, safety, efficiency, and population health.

Funder: The Department of Health and Human Services Office of the National Coordinator for Health IT (ONC). Funding has ended for the Beacon Communities however many still exist and have launched expanded IT and quality initiatives in their communities.

Reach: 17 selected communities throughout the United States. The following states had/have Beacon Communities CA, CO, HI, IN, LA, ME, MI, MS, MN, NC, NY, OH, OK, PA, RI, UT, WA. Visit the website for specific location of the Beacon Community in your State.

Do they report NQF 18, NQF 59 or other CVH diabetes data? In some cases yes, however the Beacon Communities have different goals and aims so data reporting does vary. You should check with the Beacon Community website for specific details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Example from Hawai'i Island Beacon Community (HIBC). HIBC developed a series of inter-connected approaches which lay the foundation for transformative change integrating clinical care delivery transformation, health information technology and community engagement focused on wellness and prevention on Hawai'i Island.

HIBC Areas of Focus

1. Clinical Transformation- through the collaborative creation of improved systems and workflows.
2. Technology - tools to connect all participants in the health care system, overcome geographical and socioeconomic challenges, and enhance access and quality of care.
3. Wellness and Prevention - fostering healthy behaviors through lifestyle choices, disease prevention, and personal health management will yield longstanding positive results.

HIBC Target Quality Measures addressed four key program aims and demonstrated significant progress toward meeting related quality measures in 2012:

Aim 1: Improve access to care

Aim 2: Avert the onset/advancement of diabetes, hypertension, and lipidemia

Aim 3: Reduce health disparities for Native Hawaiians and other populations at risk

Aim 4: Achieve electronic health records (EHR) adoption and meaningful use

Result have been seen in the technology that local providers now use every day to track, access, analyze and share patient information. It shows in the innovative clinical approaches and resources that are being developed, tested and applied, particularly for those with chronic diseases.

For More Information Visit: Beacon Community Program

Buying Value is an initiative of private health care purchasers-employers, leading business health organizations, and union health funds. The initiative seeks to achieve better care and lower health costs for the people it represents by replacing the current volume-based purchasing model in health care with one based on quality and patient safety. It works closely with consumer organizations and is dedicated to supporting the Partnership for Patients and other quality/safety initiatives. The initiative is designed to encourage and assist private purchasers changing from the traditional volume-based purchasing model of paying for care based on the number of individual tests or procedures performed to a model that emphasizes coordination, patient safety, and care that is proven to work.

Funder: Robert Wood Johnson Foundation

Reach: The initiative is made up of 19 organizations that either represent, or are themselves, large health care purchasers-including Fortune 500 corporations, union health funds, and national and regional business coalitions. National consumer organizations are also involved.

Do they report NQF 18, NQF 59 or other CVH diabetes data? In October 2012, the group began meeting with Federal agencies, including the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), to discuss an approach for developing common performance measures for value purchasing among public and private payers, and leveraging work by the Measures Application Partnership. As of February 2013, the Buying Value purchasers reached agreement with leading health plans on an initial core set of ambulatory care measures for use by health plans and private purchasers. The Buying Value Common Measures list now includes 35 measures; 20 of these measures are part of Stage 2 Meaningful Use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Examples of these measures include:

• Use of High Risk Medications in the Elderly (NQF# 0022)
• Timely Transmission of Transition Record (NQF# 0648)
• Blood Pressure Control (NQF# 0018)
• Comprehensive Diabetes Care: HbA1C < 8% (NQF# 0575)

For More Information Visit: Buying Value

The State Innovation Models Initiative is providing up to $300 million to support the development and testing of state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. The projects will be broad based and focus on people enrolled in Medicare, Medicaid and the Children's Health Insurance Program (CHIP).

Funder: Centers for Medicare and Medicaid Services

Reach: The SIM Initiative has 25 States participating within three different model levels. Those levels include Model Testing Awards, Model Design Awards, and Model Pre-testing Awards. Depending on what model a state is participating, timeframes vary some over 6 months while others up to 42 months.

Do they report NQF 18, NQF 59 or other CVH diabetes data? In some cases yes, however the State and Model levels have different goals and aims so data reporting does vary. You should check with the website for specific details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Arkansas State Innovation Model: The Arkansas model for a sustainable, patient-centered health care system is based on two complementary strategies-population-based care delivery and episodes-based payment-that are being launched statewide with the support of both public and private insurers.

Under provisions of the plan, by 2016 a majority of Arkansans will have access to a patient-centered medical home, which will provide comprehensive, team-based care with a focus on chronic care management and preventive services. Persons with complex or special needs (e.g., developmental disabilities) will also have access to health homes, which will work with their medical homes to coordinate medical, community, and social support services. Payments will include performance-based care coordination fees, as well shared savings for medical homes based on their ability to reduce total cost of care while also achieving goals for quality.

Arkansas will also continue to institute and expand its system of episode-based care delivery for acute, procedural, or ongoing specialty care conditions, using a retrospective payment approach that will reward providers who deliver high-quality, cost-effective and team-based care across an entire episode of care. Service for special needs populations will be further enhanced by payments reflecting each client's assessed level of need.

For More Information Visit: State Innovation Models Initiative

The Centers for Disease Control and Prevention (CDC) continues its long-standing dedication to improving the health and wellness of all Americans through the Community Transformation Grant (CTG) Program. CDC supports and enables awardees to design and implement community-level programs that prevent chronic diseases such as cancer, diabetes, and heart disease. The program is expected to improve the health of more than 4 out of 10 U.S. citizens - about 130 million Americans. CTG supports state and local government agencies, tribes and territories, nonprofit organizations, and communities across the country.

Funder: Centers for Disease Control and Prevention (CDC)

Reach: In 2011, CDC awarded $103 million to 61 state and local government agencies, tribes and territories, and nonprofit organizations in 36 states, along with nearly $4 million to 6 national networks of community-based organizations.

In 2012, CTG was expanded to support areas with fewer than 500,000 people in neighborhoods, school districts, villages, towns, cities, and counties to increase opportunities to prevent chronic diseases and promote health. In an effort to reach more people, approximately $70 million was awarded to 40 communities to implement broad, sustainable strategies that will reduce health disparities and expand clinical and community preventive services that will directly impact about 9.2 million Americans.

Do they report NQF 18, NQF 59 or other CVH diabetes data? In some cases yes, however the various CTG Initiatives and communities have different goals and aims so data reporting does vary. You should check with the website for specific details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Iowa: Twenty-six rural Iowa counties have been identified as having high stroke mortality rates. High stroke morality is especially concentrated in an area in southeast Iowa.

By September, 2016, Iowa will increase the number of dental practices having systems in place for blood pressure and tobacco use screening and referral.

The state of Iowa is building on a previous strategy ("2009-2011 Iowa Dental Pilot") in asking dental practices throughout southeast Iowa counties to voluntarily participate in blood pressure and tobacco use screening and referral training. This activity may help to ensure that more than 300,000 individuals are screened for risk factors and referred to necessary resources. In addition, this training will be offered to community health center dental clinics to ensure these activities are extended to reach low-income and uninsured populations.

For More Information Visit: CTG

The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.

Funder: Centers for Medicare and Medicaid Services

Reach: The CPC is focused in seven selected localities across the country including Arkansas, Colorado, New Jersey, New York Capital District-Hudson Valley Region, Ohio and Kentucky Cincinnati-Dayton Region, Oklahoma Greater Tulsa Region and Oregon. There are 497 participating sites involved in the Comprehensive Primary Care Initiative

Do they report NQF 18, NQF 59 or other CVH diabetes data? Data reporting does vary. You should check with the website for specific details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Ohio Comprehensive Primary Care Initiative: Cincinnati-Dayton region of Ohio is one of seven geographic markets to carry out the Comprehensive Primary Care (CPC) initiative. Seventy-five practices in the Cincinnati-Dayton market have been selected to participate in the CPC initiative. These Ohio and Kentucky practices represent 261 physicians. Designed to strengthen the primary care system and lower costs through improvement, the CPC initiative will offer a blended payment model from public and private payers.

Physicians in these practices will receive a monthly care management fee averaging $20 per month for the first two years ($15 per month for years three and four) for each Medicare patient in addition to the traditional fee-for-service reimbursement to support these enhanced primary care services:

• Improved care coordination
• Increased access to care for patients
• Preventive care delivered
• Patient and caregiver engagement in managing care
• Individualized, enhanced care for patients living with multiple chronic diseases and higher needs.

For More Information Visit: Comprehensive Primary Care Initiative

The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice demonstration will show how the patient-centered medical home model can improve quality of care, promote better health, and lower costs. This demonstration project, operated by the Centers for Medicare and Medicaid Services in partnership with the Health Resources Services Administration (HRSA), will test the effectiveness of doctors and other health professionals working in teams to coordinate and improve care for up to 195,000 Medicare patients. To help participating FQHCs make these investments in patient care and infrastructure, they will be paid a monthly care management fee for each eligible Medicare beneficiary receiving primary care services. In return, FQHCs agree to adopt care coordination practices that are recognized by the National Committee for Quality Assurance (NCQA).

Funder: Centers for Medicare and Medicaid Services

Reach: This is a three year demonstration program running from November 1, 2011 and ending October 31, 2014. There are 474 participating practice sites involved in the FQHC Advanced Primary Care Practice Demonstration from across the United States. Check with the website to see which FQHCs are participating in your State.

Do they report NQF 18, NQF 59 or other CVH diabetes data? Participating FQHCs are expected to achieve Level 3 patient-centered medical home recognition, help patients manage chronic conditions, as well as actively coordinate care for patients. In order to achieve NCQA PCMH recognition an FQHC must successfully pass and comply with all 10 must-pass PCMH elements. Some example of elements related to Domain 3 CVH & diabetes work:

• Use of paper or electronic charting tools to organize clinical information
• Use of data to identify important diagnoses and conditions in practice
• Adoption and implementation of evidence-based guidelines for three chronic or important conditions (such as diabetes & CVD)

You should check with the website for more specific data reporting details.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Those participating in the Federally Qualified Health Center Advanced Primary Care Practice demonstration are transforming their care to a patient centered medical home model. As part of that transformation that must address care and quality improvement initiatives in many of the key CVH and diabetes areas. You will find that these FQHCs are specifically improving on the management of hypertension and diabetes through work that is directly in line with Domain 3 enhanced and optional measures such as implementation of electronic health records, team-based care, patient self-management and medication adherence.

For More Information Visit: FQHC Medical Home

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides the Department of Health & Human Services (HHS) with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange.

Under HITECH, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified electronic health records technology and use it to achieve specified objectives.

Electronic health records can provide many benefits for providers and their patients, but the benefits depend on how they're used. "Meaningful Use" is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.

Four regulations have been released, two of which define the "meaningful use" objectives that health care providers must meet to qualify for the bonus payments, and two of which identify the technical capabilities required for certified EHR technology.

• Incentive Program for Electronic Health Records : Issued by CMS, these final rules define the minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for the payments for Stages 1 and 2 of meaningful use.
• Standards and Certification Criteria for Electronic Health Records : Issued by the Office of the National Coordinator for Health Information Technology (ONC), these rules identify the standards and certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they adopt are capable of performing the required functions.

Stages of Meaningful Use

The U.S. Department of Health and Human Services recently announced the release of the final rules for Stage 2 of meaningful use and updated certification criteria and standards. Learn more about the final rules and read about meaningful use clinical quality measures .

For More Information Visit these Links:
HealthIT.gov

CMS.gov

The Centers for Medicare & Medicaid Services established a Medicare Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers may participate in the Medicare Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).

The Medicare Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by:

• Promoting accountability for the care of Medicare FFS beneficiaries
• Requiring coordinated care for all services provided under Medicare FFS
• Encouraging investment in infrastructure and redesigned care processes

The Medicare Shared Savings Program will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care.

Funder: Centers for Medicare & Medicaid Services

Reach: Throughout the United States

Do they report NQF 18, NQF 59 or other CVH diabetes data?

Yes, as part of the CMS ACO initiative, before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS measures quality of care using nationally recognized measures in four key domains:

1. Patient/caregiver experience (7 measures)
2. Care coordination/patient safety (6 measures)
3. Preventive health (8 measures)
4. At-risk population:
   Diabetes (NQF 59 and NQF 0729)
   Hypertension (NQF 18)
   Ischemic Vascular Disease (NQF 75 and NQF 68)
   Heart Failure (NQF 83)
   Coronary Artery Disease (NQF 74 and NQF 66)

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Those participating in Medicare Shared Savings Program have focused their patient centered care and quality improvement initiative in many of the key CVH and diabetes areas. They are improving on management of hypertension and diabetes and in many cases focused attention on addressing tobacco use, aspirin therapy, and cholesterol (Lipid management).

For More Information Visit: CMS Shared Savings Program

Million Hearts® is a public-private initiative led by CDC and CMS to prevent 1 million heart attacks and strokes in the U.S. over the next five years by focusing the nation on evidence-based community and clinical prevention actions. Heart disease and stroke are two of the leading causes of death in the United States, making cardiovascular disease responsible for one of every three deaths in the country. Together, heart disease and stroke are among the most widespread and costly health problems facing the nation, accounting for $444 billion in health care expenditures and lost productivity in 2010 alone.

Million Hearts® priorities include:

Empowering Americans to make healthier choices by preventing tobacco use and limiting sodium and trans fat consumption. This can reduce the number of people who need medical treatment such as blood pressure or cholesterol medications to prevent heart attacks and strokes.

Improving care for people who do need treatment by encouraging a targeted focus on the "ABCS" - Aspirin for people at risk, Blood pressure control, Cholesterol management and Smoking cessation - which address the major risk factors for cardiovascular disease and can help to prevent heart attacks and strokes.

Your help is vital to the success of Million Hearts®

Your help in engaging government, health care providers, consumers, and other groups at the regional, state and local level is vital to the success of Million Hearts®.

Actions you can take to advance Million Hearts® at the regional, state, and local levels include the following:

Drive awareness of the initiative. Conduct presentations and host partner recruitment events with existing coalitions, leadership groups, advisory groups or committee meetings; push out earned media; share success stories; pledge your organization's commitment on the
Million Hearts® website , and recruit at least 20 partners to do the same.

Align existing national and state initiatives with Million Hearts® goals. Examples include education programs, tobacco prevention, worksite wellness/business programs, prevention collaboratives, health information exchanges, Beacon Communities, Regional Extension Centers, provider or community recognition programs, clinical innovation programs and medication therapy management programs.

The Association of State and Territorial Health Officials (ASTHO) recently convened an Expert Roundtable on the Role of Public Health to Support Million Hearts®. Members of the Expert Roundtable included state health officials, chronic disease directors, ASTHO affiliates, federal partners, academia, and provider organizations.

Specific recommendations and key themes from the roundtable include:

• Catalyze policy and environmental change
• Convene a wide variety of stakeholders
• Raise awareness, educate, and engage patients, providers, and other stakeholders
• Improve and integrate metrics and data management
• Expand coverage for preventive services and integration efforts
• Consider alternative funding mechanisms to sustain efforts
• Identify and promote models that leverage "natural integrators"
• Identify, develop, and share success stories, tools and resources

For additional information visit: ASTHO's Million Hearts® Initiative

For more resources and information visit: Million Hearts®

The Pioneer ACO Model is designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program. And it is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients.

Funder: Centers for Medicare & Medicaid Services

Reach: There are 32 ACOs participating in the Pioneer ACO Model. Click on the CMS Pioneer ACO Fact Sheet for complete list of participating ACOs and locations.

Do they report NQF 18, NQF 59 or other CVH diabetes data?

Yes, as part of the CMS ACO initiative, before an ACO can share in any savings created, it must demonstrate that it met the quality performance standard for that year. CMS measures quality of care using nationally recognized measures in four key domains:

1. Patient/caregiver experience (7 measures)
2. Care coordination/patient safety (6 measures)
3. Preventive health (8 measures)
4. At-risk population:
   Diabetes (NQF 59 and NQF 0729)
   Hypertension (NQF 18)
   Ischemic Vascular Disease (NQF 75 and NQF 68)
   Heart Failure (NQF 83)
   Coronary Artery Disease (NQF 74 and NQF 66)

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

Those participating in Pioneer ACO Model have focused their patient centered care and quality improvement initiatives in many of the key CVH and diabetes areas. They are improving on management of hypertension and diabetes and in many cases focused attention on addressing tobacco use, aspirin therapy, and cholesterol (Lipid management).

In addition, you will find that Pioneer ACOs are improving on the management of hypertension and diabetes through work that is directly in line with Domain 3 enhanced and optional measures such as implementation of electronic health records, team-based care, patient self-management and medication adherence. From American Medical Group Association "A core component of ACO is Care coordination: Through the use of an electronic medical record; dedicated care managers to monitor and provide timely interventions; use of evidence-based guidelines; systematic monitoring of patient quality and efficiency; and coordination among provider specialties and settings. Ensuring that patients receive the care they need, when they need it."

For More Information Visit: CMS Pioneer ACO Model

QIOs are charged with promoting health care system changes that will lead to improvements in cardiovascular and diabetes health. State cardiovascular and diabetes programs are encouraged to explore opportunities for partnership with QIOs especially on the Improving Health for Populations and Communities (IHPC) section of the 10th scope of work. In most states, you will find the QIOs working with physician offices, clinics, and other providers to create Learning and Action Networks (LAN) focused on achieving the elements of the Million Heart's® ABCS.

Funder: Centers for Medicare & Medicaid Services (CMS)

Reach: CMS contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction's Quality Improvement Organization (QIO) contractor. QIOs are private, mostly not-for-profit organizations, which are staffed by professionals to implement improvements in the quality of care available throughout the spectrum of care. QIO contracts are 3 years in length, with each 3-year cycle referenced as an ordinal Statement of Work (SOW). QIOs are currently in their 10th SOW.

Do they report NQF 18, NQF 59 or other CVH diabetes data? QIOs are aligned with national quality improvement programs. The QIO works closely with clinical practices and health systems to support the reporting to national initiatives such as Pioneer ACOs, Patient Centered Medical Home (PCMH), Physician Quality Reporting System (PQRS) and Meaningful Use. As you'll find under the National Initiatives and Health IT Buttons these programs are required to report on quality performance standards which include NQF 18 Hypertension and NQF 59 Diabetes performance measures. In addition, most of these national initiatives require reporting on cardiovascular and diabetes Domain 3 enhanced and optional measures such as implementation of electronic health records, team-based care, patient self-management and medication adherence.

CMS is required to publish a Report to Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program.

Strategies for collaboration with QIOs:

• Include QIOs and Regional Extension Centers (REC) in State CVH planning bodies, task forces, advisory bodies.
• If the opportunity exists, actively participate on QIO cardiac learning and action networks (LAN) advisory bodies and/or planning committees.
• Assist with development of a sustainability plan for the provider LANs beyond this scope of work.
• Utilize quality improvement results shared by partners/LAN members through the QIO established processes.

Example of how this work connects with the implementation of 1305 Domain 3 cardiovascular and diabetes strategies and performance measures?

The New York State Department of Health (NYSDOH) is partnering with its state quality improvement organization (QIO), IPRO (formerly the Island Peer Review Organization), to implement New York's Cardiovascular Population Health Initiative (NY CPHI). The CPHI aims to reduce risk factors and improve health outcomes for patients with CVD or at high risk of developing CVD in approximately 150 practices across the state through quality of care improvement at the practice level. These improvements will be achieved by providing technical assistance and practice support to enhance access and continuity of care, identify and manage practices' patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, and measure and improve performance around the ABCS.

Connect with your local CMS Quality Improvement Organization .